CLINICAL DOCUMENTATION SPEC

If you are motivated by the opportunity to make a meaningful impact on patient care while using your clinical knowledge and analytical skills, this Clinical Documentation Specialist role at Premier Health offers a highly rewarding career path. In this position, you will help ensure the medical record accurately reflects each patient's severity of illness, the services provided, and the quality of care delivered. Your expertise will directly support compliant documentation, accurate coding, and improved outcomes across the healthcare continuum.

Premier Health offers the chance to join an organization known for its commitment to excellence, collaboration, and service. As a respected healthcare employer, Premier Health fosters a professional environment where employees are supported in their growth, encouraged to contribute ideas, and recognized for the value they bring to patients, providers, and the broader care team. This role is ideal for a clinically knowledgeable and detail-oriented professional who wants to work at the intersection of patient care, documentation integrity, and healthcare quality.

In this position, you will feel connected through close collaboration with physicians, nursing teams, ancillary departments, and coding professionals. Your work will play a vital role in strengthening communication across disciplines and ensuring the clinical picture is clearly and accurately documented. Employees who thrive at Premier Health value the teamwork-oriented culture, the meaningful nature of the work, and the opportunity to contribute to organizational goals that support patient satisfaction, compliance, and operational excellence.

The Clinical Documentation Specialist is responsible for facilitating accurate and compliant documentation by improving the overall quality and completeness of the medical record. Through utilization of clinical expertise, this role ensures the patient's severity of illness is captured in the medical record. The specialist guides physicians, nursing, and ancillary staff on clinical documentation best practices and works closely with coding professionals to ensure the coding summary reflects the level of service provided. This position requires a broad clinical knowledge base to accurately review the patient medical record for diagnosis clarification, principal diagnosis accuracy, and capture of additional comorbid conditions, including HACs, focused PSIs, and Vizient risk-adjusted diagnoses.

• Analyze clinical documentation for assigned patients and make recommendations for appropriate DRG assignment.
• Facilitate appropriate clinical documentation to support accurate diagnosis coding and ensure the level of service rendered is fully recorded.
• Complete admission reviews with the most appropriate principal diagnosis, complicating conditions, and supporting documentation to reflect severity of illness in compliance with government regulations.
• Identify opportunities for documentation clarification and complete clinically based queries.
• Perform timely follow-up on outstanding queries and document outcomes appropriately.
• Prioritize and utilize time effectively while adhering to employment policies and productivity expectations.
• Participate as a team member in achieving department-specific goals and metrics.
• Maintain required training, competencies, and educational requirements, including Healthstream assignments.
• Support the professional development of peers, care team members, and orientees while participating in performance improvement activities.
• Complete initial and follow-up medical record reviews using an organized approach across admit notes, medical history, medications, provider documentation, treatments, orders, ancillary notes, and laboratory data.
• Analyze and interpret clinical data to identify documentation gaps, inconsistencies, and opportunities for improvement using the concurrent query process.
• Formulate credible clinical documentation clarifications related to principal diagnosis, co-morbidities, POA status, quality core measures, and PSIs.
• Assign appropriate DRG/APR-DRG, MCCs, and CCs to each reviewed record in the CDI documentation system using coding rules and guidelines.
• Educate providers regularly to enhance understanding of the Clinical Documentation Improvement program.
• Collaborate with clinical disciplines and coding department staff to promote high-quality documentation and timely coding.
• Conduct post-discharge reviews for comparative analysis of CDI Specialist and Coding DRG assignment.
• Develop collaborative relationships and promote teamwork with coworkers and other departments.
• Organize and perform work responsibilities effectively and efficiently.
• Maintain strict patient confidentiality in adherence with HIPAA guidelines.
• Demonstrate Premier Health's strategic goals and behavioral expectations, including teamwork, communication, compassion, accountability, and service excellence.

The Clinical Documentation Specialist is responsible for facilitating complete and compliant documentation. Through utilization of their clinical expertise they ensure the patient's severity of illness is accurately portrayed in the medical record. They are responsible for guiding physicians, nursing, and ancillary staff on clinical documentation best practices and working closely with the coding professionals to increase coding accuracy.

• Bachelor's degree required.
• Bachelor of Science in Nursing, Health Information Management, or equivalent medical degree preferred.

Area of study in Nursing, HIM, or as a medical college graduate.

• Current license to practice professional nursing in the State of Ohio or reciprocal states; or USMLE/ECFMG certification for foreign-trained graduates, as applicable.
• Certified Clinical Documentation Specialist (CCDS) or Certified Coding Specialist (CCS) certification preferred.
• 3 to 5 years of related experience required.
• Previous experience as a Nurse, Coder, or medical college graduate strongly preferred.

Strong critical thinking, problem-solving, and analytical skills with the ability to integrate knowledge.

Exemplary interpersonal skills with the ability to build rapport with physicians, peers, and healthcare team members.

Negotiation, conflict resolution, and assertive communication skills required.

Ability to multi-task and work effectively with interruptions.

Teamwork oriented with strong professionalism, tact, and diplomacy.

Strong organizational, analytical, and prioritization skills.

Effective oral and written communication skills.

High degree of confidentiality required.

Basic computer knowledge and skills required.

Broad clinical knowledge base necessary to review a wide variety of medical records.

Proficiency in EPIC, 3M, Midas, CDE One, and other related software programs.

Knowledge of ICD-10 coding required.

Education: BSN required

Licensure: Registered Nurse with valid Ohio license

Certification: Certification in Clinical documentation, CPHQ, or Case Management preferred

Experience: Minimum of three years of relevant clinical experience in area of patient population within

last five years. Solid working knowledge of healthcare reimbursement preferred.

Skills/Other: Strong critical thinking, problem solving, and analytical skill with the ability to integrate knowledge is required. Exemplary interpersonal skills as demonstrated by the ability to develop and maintain rapport with physicians, peers, and other members of the healthcare team. Negotiation skills, conflict resolution skills and assertive communication skills required. Computer skills expected.

If you are ready to bring your clinical expertise, coding knowledge, and documentation improvement skills to a respected healthcare organization, consider applying for the Clinical Documentation Specialist opportunity at Premier Health. This is your chance to join a collaborative team where your work will influence care quality, compliance, and patient outcomes every day. Apply now to take the next step in a meaningful and professionally rewarding career.